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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603382
Report Date: 01/30/2024
Date Signed: 01/30/2024 06:09:41 PM


Document Has Been Signed on 01/30/2024 06:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ASPIRIA ADULT RESIDENCESFACILITY NUMBER:
198603382
ADMINISTRATOR:VILLA, MEYNARDFACILITY TYPE:
740
ADDRESS:342 W. PALM DRIVETELEPHONE:
(626) 672-8439
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY:6CENSUS: 6DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:06 AM
MET WITH:Administrator Meynard VillaTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 01/30/2024. LPA was met by Caregiver Lamosha Anderson and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which six (6) may be non-ambulatory, of which one (1) may be bedridden and approved hospice waiver for two (2). Bedroom#5 is cleared for bedridden and all bedroom doors and hallway doors must not be propped open or contain door stops.
LPA OBSERVATIONS: The facility is a single-story dwelling located in a residential neighborhood and consist of five (5) resident bedrooms, four (4) shared full bathrooms, one (1) ½ bathroom, kitchen, dining room, living room, laundry room, attached garage, front yard, and backyard.

Front Yard: Front yard is well maintained, and no hazards were observed.

Kitchen: LPA Ramirez observed black short gate around kitchen entry. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps to be located in nearby cabinet and was observed to be inaccessible to five (5) out of five (5) residents in care. Kitchen sink water temperature was measured at 126.3-degree F. Licensee placed sign indicating “Caution water may rise above 125 degree F” during visit. Medications were observed to be centrally stored in nearby kitchen cabinet and was inaccessible to five (5) out of five (5) residents in care.

Dining Room/Living room/: Dining room was observed to contain one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed nearby thermostat in this area to read 72 degree F. LPA Ramirez observed all three hallways doors to be propped open by door stopper. LPA Ramirez will issue Type A deficiency.

Linen Closet: Contained plenty linens, towels, and hygiene products.



Resident Rooms 1-5: LPA Ramirez inspected five (5) resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens.

See 809-C for continuation.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ASPIRIA ADULT RESIDENCES
FACILITY NUMBER: 198603382
VISIT DATE: 01/30/2024
NARRATIVE
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Bathrooms 1-4: Water temperature in all bathroom was not within 105–120 degree F. Water temperature in bathroom#1 was measured at 147.6 degree F. Water temperature in bathroom#2 was measured at 149.2 degree F. Water temperature in bathroom#3 was measured at 146.1 degree F. Water temperature in bathroom#4 was measured at 134.2 degree F. Water temperature in ½ bathroom was measured at 147.2 degree F. LPA Ramirez observed grab bars and non-slip mats in shower and grab bars near toilet. LPA Ramirez will issue Type A deficiency. Bathroom#1 sink was observed to be peeling and chipping off blue paint. LPA Ramirez will issue Type B deficiency.

Backyard: No hazards were observed. Plenty of shade and seating was observed.

Emergency Drills: According to Licensee, facility has not conducted drills or has proof of documented drills. LPA Ramirez will issue Type A deficiency.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Laundry Room: LPA Ramirez observed chemicals and disinfectants to be in locked cabinet in this room. LPA Ramirez observed extra canned goods in nearby shelf in this room.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed six (6) personnel records. Staff#1, 3, 4 and 6 did not have properly documented training in personnel records. Staff#3 did not have documented health screening in personnel record. LPA Ramirez will issue Type B deficiency.

Resident Files: Five (5) resident files were reviewed. LPA did not observe required physician’s report for R1 and R2. LPA Ramirez will issue Type B deficiency.

Liability Insurance & Infection Control Plan: LPA Ramirez obtained a copy of liability insurance during visit. LPA Ramirez observed updated infection control plan.



Deficiencies are being cited. A copy of this report, 809-D, and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 01/30/2024 06:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: ASPIRIA ADULT RESIDENCES
FACILITY NUMBER: 198603382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, five (5) faucets used for grooming water temperature was over 120 degree F, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and/or visitors, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Licensee/Administrator lowered water temperature during visit. Licensee/Administrator will develop water log and will record water temperature from 01/31/2024 through 02/06/2024 for AM and PM shifts. Water will be measured and recorded on log twice a day and emailed to LPA Ramirez by 02/07/2024.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview witrh Licensee, facility staff have not been conducting emergency drills or documenting drills, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and/or visitors, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Licensee/Administrator will certify plan to implement and review above regulation. Licensee will send certification to LPA Ramirez via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 01/30/2024 06:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: ASPIRIA ADULT RESIDENCES
FACILITY NUMBER: 198603382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, bathroom#1 sink blue paint was chipping and peeling off, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and /or visitors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2024
Plan of Correction
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Licensee/Administrator will repair or replace bathroom#1 sink. Picture proof must be sent to LPA Ramirez by 2/6/2024.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, Staff#3 did not have proof of health screening, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and/or visitors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2024
Plan of Correction
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Licensee/ Administrator will reprint health screening and place in staff#3 file. Proof of health screening must be sent to LPA Ramirez via email by 02/06/2024,
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 01/30/2024 06:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: ASPIRIA ADULT RESIDENCES
FACILITY NUMBER: 198603382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(2)(B)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (B) Subject(s) covered in the training;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, 4 out of 6 staff did not have training documented according to regulation above, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and/or visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2024
Plan of Correction
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Licensee/Administrator will certify plan to implement proper documentation of staff training per above regulation. Must be submitted via email.
Type B
Section Cited
CCR
87412(c)(2)(C)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (C) Date(s) of attendance; and

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, 4 out of 6 staff did not have training documented according to regulation above, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and/or visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2024
Plan of Correction
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Licensee/Administrator will certify plan to implement proper documentation of staff training per above regulation. Must be submitted via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 01/30/2024 06:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: ASPIRIA ADULT RESIDENCES
FACILITY NUMBER: 198603382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(2)(D)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, 4 out of 6 staff did not have training documented according to regulation above, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and/or visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2024
Plan of Correction
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2
3
4
Licensee/Administrator will certify plan to implement proper documentation of staff training per above regulation. Must be submitted via email.
Type B
Section Cited
CCR
87412(c)(2)(D)3
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject. 3. If the educational hours/units are obtained through continuing education, documentation shall include a transcript or official grade slip showing a passing mark, if applicable, or a Certificate of Completion.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, 4 out of 6 staff did not have documented transcript or offical grade slip or Certificate of Completion, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and/or visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2024
Plan of Correction
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2
3
4
Licensee/Administrator will certify plan to implement proper documentation of staff training per above regulation. Must be submitted via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 01/30/2024 06:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: ASPIRIA ADULT RESIDENCES
FACILITY NUMBER: 198603382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, 2 out of 5 residents did not have required annual medical assessment, the licensee did not comply with the section cited above in 2 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2024
Plan of Correction
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Licensee/Administrator will submit medical assessment for R1 and R2 by 2/6/2024 and send to LPA Ramirez via email.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8


Document Has Been Signed on 01/30/2024 06:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: ASPIRIA ADULT RESIDENCES
FACILITY NUMBER: 198603382

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, hallway#1, 2, and 3 door were observed to be held open by door stoppers, the licensee did not comply with the section cited above in 5 out of residents, staff and/or visitors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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2
3
4
Licensee/Administrator removed door stoppers during visit. Licensee/Administrator will certify via email that all bedroom doors or hallway doors will not be propped open and door stops must be removed, per fire clearance
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 8 of 8